69184D - Thomas

4AMA / ❑ DREDGE & FILL �% `�I -f,' CI
9�ENERAL PERMIT Previous permit# A B
New I_1Modification ❑Complete Reissue DPartiall Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC to 7 �'. 2 � t l
D. hed
nt Name LW� Th bwi
�{I'Yi State N GZIP❑ 2
E-Mail
zed Agent , F _f h
❑ CW YEW PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
no PNA yes Cno
/�' ❑ es— .
U� Project Location: County / wV f l L(o uyeK
Street Address/ State Road/ Lot #(s) �S�Z
I!Uaie /iI ihJ
Subdivision
City ^� I i 'j 1 Y" ZIP
one # () 2 G►-Lo3S} River Basin I
Adj. Wtr. Body i b YV (nat
Closest Maj. Wtr. Body -m iddit Saund
if Project/ Activity a d d ;3G t T 2 G'[ eLK `{ reW h t , id( h w
( V1101Wed, a I U S � i
ock)length
'latform(s) Z
g Platform(s) }
ad/ P�rap length_
eg dis ce offshore
iax dista a offshore
:hannel
ibic yards
mp
use/ Boatlift
ie Length !/ HAV
not sure yes no
rium: n/a yes no
yes no
Attached: yes no
(Scale:- 1 q
,I
ing permit may be required by: C �/1/ f "f % 1('✓{ V (.Q j { 2 ]r ❑ See note on back regarding River Basin i
Local Planning lurisdiction) _.

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant:
Date:
Describe below the HA ITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
M
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disc
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res'
restoration or
and/or temp
restoration or
terr
temp impacts)
impact amount)
temp impacts
am
r
�
Dredge ❑ Fill ❑ Both ❑ Other *
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
�? Sf -6 2v---;�-P.2 �
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Qd a 3S sc
at my property located at ,
inCounty.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluatng infonnation related to this
permit application.
Property Owner Information:
Signature
R. Tho ohs
Print or Type Name
Caw n o-r
Title

ADJACENT V41PARIAN PROP ERT" 0V'YN-'k,:"T �FEIAEKIT
1 hery 0 j
'edify ttlat I ov"I 1 1 e r I' o
eb
propery located a j
(Addruss, LA,
The appliCant has descr:hed to rmI, a,,., sh,,',)vvn belokvv. th
ve n
I have to fts propnsal
DESCMPITION ANDIOR DRAWING OF
(Individual pt-opw,,;"r-g development musf fill inr � iite", "J'f -,7",v `l
VVA(VER SECTIC"'
1 understand that a pie,r, dock, i'nooring pilings, breakwater. ]ift, rmus-,
minimurn, rdistance of 1 :',' fro,"" rr,,v area of riparian access ul d,3--s; a s {v n` 0"';
the setback, fvu rntist irnitial the appropriate blank belovj.',�
1,jc, vp1c.h ,1,j wa�ve ffic- 15'setback
I do riot vAsh to waive the I 5'setback
(Property Owner Information)
.. . . .... . ...... -
ru r L S
Pfir,t or -y, Namo P rr,t or TypE; tVawi

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �r. r.l f�FIC� En S s
(Name of Property Owner)
property located at L a ,., 1-
(Address, Loot, Block, Road, etc.)
on C GJ in JU .-0 NC, c:n N.C.
ate body) (City/Town and/or County)
The ap cant has described to me, as shown below, the development proposed at the above locatior
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
o ° e Ila
0
'coPoSecJ cb-cjc- 0v- .e,usi0^J
WAIVER SECTION
1 understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
the setback, you most initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Ad' cent Propertu Owner Ini
Sign e \ Si " tur
_ r" c` a c�) _�
1� - Wei
Print or Type Nathe Pnn or T )ff N�l� e

I